RES 2012-1141 - SDL for fund raiser at Plaza de la Raza, September 15-16 2012 ,
APPLICATION FOR SPECIAL
DESIGNATED LICENSE
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046 •
LINCOLN,NE 68509-5046 •
PHONE:(402)471-2571
FAX:(402)471-2814
Website:www.lcc.ne.gov/
DO YOU NEED POSTERS? YES 0 NO 0
RETAIL LICENSE HOLDERS
NON PROFIT APPLICANTS 0 •
Non Profit Status (check one that best applies)
Municipal° Political Q Fine Arts 0 Fraternal Religious 0 Charitable() Public Service
COMPLETE ALL QUESTIONS •
1. Type of alcohol to be served and/or consumed: Beer \Wine 1 ( IL Distilled Spirits
2. Liquor license number and class (i.e. C-55441) II;yf /,�, / . p',
• (If you're a nonprofit organization leave blank) F (r•
•
3. Licensee name (last, first,), corporate name or limited liability company (LLC) name
(As it reads on your liquor license)
l� ry ,r, '
NAME: / i,r ` `_ J r,; •('. r� .. AM.4-- /% )' < < /`t"� �- ".y ,/"
ADDRESS: _ -. � +�
CITY '//j/(�l l2�'. ZIP 4,7 ,l`'! ,:
4. Location where event will be held; name, address, city, county, zip code
JAMMING NAME ,f /�� j`.G,a f' -r �_ '- //..
ADDRESS: ,/ %C'7 .3ci . .%.5 S ._._ CITY
ZIP ( ,t''c/ / COUNTY and COUNTY # c'cis.) l C'fa.. c •
a. Is this location within the city/village limits? YESO
b. Is this location within the 150' of church, school, hospital or home •
for aged/indigent or for veterans and/or wives? YESF1N0 7--'
c. Is this location within 300' of any university or college campus? YESnNO ,
FORM 108
REV 5/12
• Page 2 of 5
I are respon• sible for s
r mpl ce with t tehcpnditio set out;.above :If it is.deterinined that'the above, nr4ividioi'has violated 53 l25 3 .the .
y h
Commission may cancel or revoke.the.liquor license. ,->' .t>. . ..;.. ... . ,_ '.•••
•
142 ,, ' 6u5 ) 1%• if4A-556-&J
ignature of individual involved with application Printed name of applying individual
(Spouse of individual listed above)
State of 0 Q
County of @1.. The foregoing instrument was acknowledged/ before me this
,NitijilflAkr2Z t C a by ( (AA2 /+� 4.1.( 4 411A .
d name of person ac owledged
Affix Seal
pr. OMER .NOUN-Woof*baasis
otary Public signature '' MEUSSA R.KI Y
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
FORM 35-4178
Revised 1/2008
S r{ '{ S�*I,y�
y u.,:�'i; Yi,! 471' .'.,.fl. .�.it�c'G.;} a.dr+,•'(y%';i�).'+?�y'S Fut!(• ,.sir.
" L J'• J }( 1
Y?•b'1�ii,N'tiy�'�'d�gl7 C,;�1.rik tr>,t.t't": i'e 5•�i4:1.,,1:q°�. a:f .:rn';��!1�; ,.•,S, �.�):!:.,?�j2` '.,!alt. yl 1i� rr.t;�:7:ia�,.��s•�f �14;tilf;i):c � v�i
� . :� - ,tl.+.;.,! .Ri�.M ; 41, I., )'�fi B �w1.51`+fir"vMr�iL�` ��; y`1S �'t �f�"x%{
CITY a STATE YEAR YEAR CITY&STATE - YEAR YEAR
FROM TO FROM TO
5Wr it via. 0907 - 9
A444,,Aft( fijiArkietqf 27,
Foml:O3
Rev 1112012
Pegesaff
i
5. Date(s) and Time(s) of event (no more than six(6) consecutive days on one application)
Date Date Date Date Date Date
9. i.5.,/ 9.- /i ./Z--
Hours Hours Hours Hours Hours Hours
From From From From From From
,t/1 / fill ti
To,/ , I To — To To To To
a. Alternate date:
b. Alternate location:
(Alternate date or location must be specified in local approval)
6. Indicate type of activity to be carried on during event:
111 Dance Reception $4 and Raiser Beer Garden ampling/Tasting
Other
7. Description of area to be licensed
Inside building, dimensions of area to be covered IN FEET x
(not square feet or acres),
*Outdoor area dimensions of area to be covered IN FEET 56.3` x , .2.CU
*SKETCH OF OUTDOOR AREA (or attach copy of sketch)
If outdoor area, how will remises be enclosed?
.Fence; snow fence. chain links cattle panels other
41) ent
many youexpectF `f/(`i ?,c_X 1/ram 1%z f_
8. How attendees do at event? �;
9. If over 150 attendees. Indicate the steps that will be taken to prevent underage persons from
obtaining alcohol beverages. (Attach separate shee if needed) �I� �
e-� .ck. �!� - 'Let►'�(.-t'`_ C9./Z lt.G,t'iCV, LAiiti.S - 1:9elF
. ,,ti IC I. Tc 0 A GI k to-5
10. Will premises to be covered by license comply with all Nebraska sanitation laws?YES7NO
a. Are there separate toilets for both men and women?YESFNO
/ %t l� /4� ) 111f'�
l/ /
:S / ' .-- 4✓j 7)4 /� `! ,� FORM 108
REV 5/12
Page3of5
age 2 of 5
I are respon• sible for s
r mpl ce with t tehcpnditio set out;.above :If it is.deterinined that'the above, nr4ividioi'has violated 53 l25 3 .the .
y h
Commission may cancel or revoke.the.liquor license. ,->' .t>. . ..;.. ... . ,_ '.•••
•
142 ,, ' 6u5 ) 1%• if4A-556-&J
ignature of individual involved with application Printed name of applying individual
(Spouse of individual listed above)
State of 0 Q
County of @1.. The foregoing instrument was acknowledged/ before me this
,NitijilflAkr2Z t C a by ( (AA2 /+� 4.1.( 4 411A .
d name of person ac owledged
Affix Seal
pr. OMER .NOUN-Woof*baasis
otary Public signature '' MEUSSA R.KI Y
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
FORM 35-4178
Revised 1/2008
S r{ '{ S�*I,y�
y u.,:�'i; Yi,! 471' .'.,.fl. .�.it�c'G.;} a.dr+,•'(y%';i�).'+?�y'S Fut!(• ,.sir.
" L J'• J }( 1
Y?•b'1�ii,N'tiy�'�'d�gl7 C,;�1.rik tr>,t.t't": i'e 5•�i4:1.,,1:q°�. a:f .:rn';��!1�; ,.•,S, �.�):!:.,?�j2` '.,!alt. yl 1i� rr.t;�:7:ia�,.��s•�f �14;tilf;i):c � v�i
� . :� - ,tl.+.;.,! .Ri�.M ; 41, I., )'�fi B �w1.51`+fir"vMr�iL�` ��; y`1S �'t �f�"x%{
CITY a STATE YEAR YEAR CITY&STATE - YEAR YEAR
FROM TO FROM TO
5Wr it via. 0907 - 9
A444,,Aft( fijiArkietqf 27,
Foml:O3
Rev 1112012
Pegesaff
I; •
..23 ST.
l'r• Y SWO0111638/SONVS }:.
..,.: i. •.
f..
ram' :.:._- ::,.
,.i y
O ''•r: I
J Iy
.
h
`(1 iI,i,t
r A)- ,._.:,•
4I
l,:i rf
r
. RESTROOMS ' . .
,
1
n
CD .4. 0LAA)
r
•
,k
p
N
CD
O rs(D P %
I\
k
11. I'.etailer: Will you be purchasing your alcohol from a wholesaler? YES NO
Non-Profit: Where will you be purchasing your alcohol?
Wholesaler a Retailer 0 !:,oth 0 BYO°
(includes wineries)
12. Will there be any games of chance operating during the event? YES11NO
If so, describe activity —j'
NOTE: Only games of chance approved by the Department of Revenue,Charitable Gaming Division are permitted. All other forms of
gambling are prohibited by State Law: There are no exceptions for Non Profit Organizations or any events raising funds for a charity.
This is only an application for a Special Designated License under the Liquor Control Act and is not a gambling permit application.
13. Any other information or requests for exemptions:
•
14. Name and telephone number/cell phone number of immediate supervisor. This person will be at
the location of the event when it occurs, able to answer any questions from Commission and/or.law
enforcement before and during the event, and who will be responsible for ensuring that any applicable
laws, ordinances, rules and regulations are adhered to. PLEASE PRINT LEG!L,LY
Print name of Event Supervisor j, i: rT ,.-i� `1 c1, (if
Signature of Event Supervisor 7_— r-� 0cam il_ct (-[L.i.9.-G=t
Phone of Event Supervisor: Before Lf(-Z. .3 j`i f/L/` d— During ' 3 C i '►'.2.K
Consent of Authorized Representative/Applicant •
15. I declare that I am the authorized representative of the above named license applicant and that the
statements made on this application are true to the best of my knowledge and belief. I also consent to
an investigation of my background including all records of every kind including police records. I
agree to waive any rights or causes of action against the Nebraska Liquor Control Commission, the
Nebraska State Patrol or any other individual releasing said information to the Liquor 'Control
Commission or the Nebraska State Patrol. I further declare that the license applied for will not be
used by any other person, group, organization or corporation for profit or not for profit and that the
event will be supervised by persons directly responsible to the holder of this Special Designated
License.
•
sign /
here ��(:i,C ft� i �[r'z�l -�1 .!d,t,�4> ,../ O �is-
Auth i i ed Representative/Applicant Title Date
111 r-/C' ,A si a ic",;. q-- . '
Print Name
This individual must be listed on the application as an officer or stockholder unless a letter has been filed appointing an individual
as the catering manager allowing them to sign all SDL applications.
The law requires that no special designated license provided for by this section shall be issued by the Commission without the approval of the
local governing body. For the purposes of this section,the local governing body shall be the city or village within which the particular place for
which the special designated license is requested is located,or if such place is not within the corporate limits of a city or village,then the local
governing body shall be the county within which the place for which the special designated license is requested is located.
FORM 108 .
REV 5/12
Page 4 of 5
r�iL�` ��; y`1S �'t �f�"x%{
CITY a STATE YEAR YEAR CITY&STATE - YEAR YEAR
FROM TO FROM TO
5Wr it via. 0907 - 9
A444,,Aft( fijiArkietqf 27,
Foml:O3
Rev 1112012
Pegesaff
00 \ k'10 Iv °
? / 7 ° ]. •_ EI §. a
a \ t71 E Clg_ ° R > §\
U a q / §' §' \ 8
, o
E d . ' cp ko
2 q = p / ti
J.
A )` 3 CA
�� §C A) 2' G 7 _ " .
" n
0 p 0
q ¢ C & § �cr'p
$ 2 E o
q CD . ® 8' e n- /
F. ¢ • 0 \ 4) -
G § - ] q § 2 U
K Q 0 C °
° § G
kc k g f 0 . .
/
, . \
.
\